Discussion and Conclusion

The SUSTAINS Case: Analysis of current case has shown that HCI best practice was not followed by the customer for any of the three phases. Overall, the project applied a scarce amount of user participation. “The users’ needs were known to some extent by the aid of a survey conducted in 1999 and by the experiences made in the private

Development of Novel eHealth Services 377

general practice” (R2) Instead of an inventory among patients today, the customer (particularly the project owner) tried to take on the role of a future end-user based on the reasoning that it was future end users’ needs which were of importance: “An average patient of today cannot know what she needs and demands from a future eHealth service system, as her views on and ideas of health and health systems will change, along with her own behavior”. Moreover, no stated project- or effect goals made development and evaluation difficult. The logic was, that “if a stated goal is invalid according to a future user it will not matter if the system can fulfill the goal or not”. According to HCI best practice, that uncertainty can be decreased using different user centered methods and techniques.

The vendor was only involved in the intermediate phase of the project regarding development of the services from specifications provided by the customer.

Fortunately, the customer was supported by the vendor in handling some end-user issues and the moving targets. Use of an agile development method brought the common understanding of expected results forward as the customer collaborated closely with the vendor’s development team in frequent sprint demos. Further, an initial inspection evaluation led to redesign of the entire prototype as well as creation and use of three personas during development and sprint demos [19]. The usability aspects could be further refined, in many cases usability was neglected by the system’s owner: “As far as I remember no one was responsible for usability aspects”

(R5). “We have made no usability testing of the system” (R6) and currently “no one knows whether the eHealth services are useful or only an online service” (R5).

Recommendations to Public Authority Customers: Although research has long advocated cooperative design methodologies, current public e-service projects are still technology-driven, instead of focusing on potential user needs. Use of existing and modified methods and techniques from the field of HCI as referenced here are of great value. In order to grasp this knowledge, it may be wise to incorporate HCI experts, not only from the vendor, but also internally, to establish a proper know-how of how to involve users to gain value out of the participation. In industry, usability experts are engaged in other projects, and only when called for their knowledge will be available for e-Government projects. It is therefore important to build in usage considerations early in planning and procurement documents, as well as working towards leaving conventional customer-vendor processes in favor of cooperative and agile methods. When HCI knowledge lacks at the customer end, which is not rare in healthcare, the developer must be given a mandate to handle these issues. In current case, the customer was led into development methods and processes selected by the vendor, in order to jointly develop a public e-service. In our opinion this project was saved by applying evolutionary prototyping, a thorough inspection evaluation and use of personas, where the customer meritoriously played user representatives using the 3 personas during iterative demos. However, working with future user-methodologies in a cooperative manner increases the likelihood for successful deployment according to best practice.

378 I. Scandurraet al.

Proposed New Actions for HCI Research Agenda: By this study we inform the HCI domain where practice really is standing, and we propose a call for action, to support public authorities/public care providers by leading them towards a collaborative and user-centered development environment in an action research setting.

Constructive evaluations of novel eHealth services need to be performed, not only usability tests in a user context in current project, but in all projects. HCI researchers could assist e.g. in a triple helix-constellation with public sector and industry to build e-services that meet future users’ needs and possibly saving resources in the society.

Moreover, defined goals are needed. In this case e.g. how the system is intended to contribute to the patients’ well-being, how or how much the system should ease the pressure on different services provided by healthcare today, or what impact the new eHealth services should have on the workload of certain clinical staff. Support from research in creating e.g. efficiency goals would benefit public e-service projects.

There is a need for educational projects to educate the customer to handle development processes with public user (citizen or patient)-centered perspectives. HCI researchers would also do well as mediators between customers, users and developers.

Neglecting future users and usability aspects is not unique for the studied project, on the contrary. There are recognized delimiting factors that e-government initiatives are associated with and that the HCI community could study and propose e.g.

guidelines for. Compared to services developed by commercial actors, public e-services must encompass both economic and democratic values at the same time as public administrations are regulated by laws to a large extent [20]. Being a public administration also brings the responsibility to provide e-services that provide clear benefit to the citizens since there is seldom an option to select another similar public e-service; they simply do not exist [21]. At last, users of public e-services are citizens with certain constitutional rights. Public e-services cannot exclude any user groups although they are not a majority of the users, instead all future users must be considered, taking into account different disabilities, geographical limitation, and language issues [22]. These delimiting factors make user participation in public eHealth service development a challenging and complex activity and best-practice methods are needed to support public e-service development. Future work is to further examine which HCI methods, and to what extent HCI methods, can support the process of empowering patients and making them more involved in their own health.

Acknowledgments. The DOME-project is financed by VINNOVA (2012-02233), Swedish Agency for Innovation Systems. SUSTAINS is supported by the European commission (No 297206). Special thanks go to the respondents at LUL and the development company EVRY that invited us to a Triple helix environment for future work.

References

1. Atzori, W., Ünver, Ö.: SUSTAINS User Requirements Recommendations, Report D4.1v1,2013 (May 15, 2013), http://www.sustainsproject.eu/

2. Anthopoulos, L.G., Siozos, P.S., Tsoukalas, I.A.: Applying participatory design and collaboration in digital public services for discivering and redesigning e-Government services. Government Information Quarterly 24, 353–376 (2007)

Development of Novel eHealth Services 379

3. Axelsson, K., Melin, U., Lindgren, I.: Exploring the importance of citizen participation and involvement in e-government projects - practice, incentives and organization.

Transforming Government: People, Process and Policy 4(4), 299–321 (2010)

4. Melin, U., Axelsson, K., Lundsten, M.: Talking to, not about, Entrepreneurs – Experiences of Public e-service Development in a Business Start Up Case. In: Cunningham, P., Cunningham, M. (eds.) eChallanges (2008)

5. Commission of the European communities, i2010 eGovernment Action Plan: Accelerating eGovernment in Europe for the Benefit of All, C.o.t.E. communities, Brussels (2006) 6. Henriksen, Z.H.: The diffusion of e-services in Danish municipalities. In: Traunmüller, R.

(ed.) EGOV 2004. LNCS, vol. 3183, pp. 164–171. Springer, Heidelberg (2004)

7. Schuler, D., Namioka, A.: Participatory Design Priciples and Practicies. Lawrence Erlbaum Associates Inc., London (1993)

8. Bardram, J.E.: Scenario-based design of cooperative systems: Redesigning an hospital information system in Denmark. Group Decision and Negotiation 9, 237–250 (2000) 9. Greenbaum, J., Kyng, M. (eds.): Design at work: Cooperative design of computer systems,

pp. 3–24. Lawrence Erlbaum Associates, New Jersey (1991)

10. Constantine, L., Lockwood, L.: Software for Use: A practical guide to the Essential Models and Methods of Usage-Centered Design. Addison-Wesley (1999)

11. Jungk, R., Müllert, N.: Future Workshops: How to create desirable futures. Institute for Social Interventions, London (1987)

12. Norman, D.: Cognitive engineering. In: Norman, D., Draper, S. (eds.) User-Centered System Design: New Perspectives on Human Computer Interaction, pp. 378–382.

Association for Computing Machinery, NY (1986)

13. Gulliksen, J., Göransson, B., Cajander, Å., et al.: Key principles for user-centred systems design. Behaviour and Information Technology 22(6), 397–409 (2003)

14. Mulder, S., Yaar, Z.: The User Is Always Right: A Practical Guide to Creating and Using Personas for the Web. New Riders Press (2006)

15. Nielsen, J.: Heuristic Evaluation, Usability Inspection Methods. John Wiley & Sons, New York (1994)

16. Beyer, H., Holtzblatt, K.: Contextual Design. Defining Customer-Centered Systems. San Fransisco. Morgan Kaufmann Publishers, San Fransisco (1998)

17. Avison, D., Fitzgerald, G.: Information Systems Development. McGraw Hill Higher Education (2006)

18. Brender, J.: Handbook of evaluation methods for Health Informatics. USA Elsevier Academic Press, USA (2006)

19. Cajander, Å., Larusdottir, M., Gulliksen, J.: Existing but not Explicit – The User Perspective in Scrum Projects in Practice. In: INTERACT 2013 LNCS Proceedings, INTERACT 2013, Cape Town, South Africa (2013)

20. Karlsson, F., et al.: Exploring user participation approaches in public e-service development. Government Information Quarterly 29(2), 158–168 (2012)

21. Lindgren, I., Jansson, G.: Electronic services in the public sector: A conceptual framework.

Government Information Quarterly 30(2), 163–172 (2013)

22. van Velsen, L., et al.: Requirements engineering for e-Government services: A citizen-centric approach and case study. Government Information Quarterly 26(3), 477–486 (2009)

Paper IV

European Journal of ePractice · http://www.epractice.eu/en/journal/

A necessary activity towards moving healthcare services out of the physical premises of hospitals and into patients’ daily lives is to supply citizens with various health services via the Internet, i.e. public eHealth services. However, developing public eHealth services for a large number of heterogeneous end-users is a complex task.

This case study investigated the development process of a novel eHealth service that provides patient access to electronic health records, which was developed and recently deployed within the scope of an EU project.

A conventional customer-vendor process was applied that resulted in a high degree of uncertainty regarding end-user needs of this novel service. The development team tried to compensate for this weakness by using agile methods. When developing public eHealth services for citizens, it is imperative to involve potential users, to evaluate the citizens’ needs as a function of benefit, usability and security, and to handle those concepts responsibly throughout the process.

Acknowledgements

The action research project ‘DOME - Deployment of Online Medical Records and eHealth Services’ is financed by VINNOVA (2012-02233) – Swedish Governmental Agency for Innovation Systems. The SUSTAINS implementation project is supported by the European Commission (No 297206). Special thanks go to the respondents at the Uppsala County Council and at the development company EVRY for inviting us to form a Triple Helix environment for future work.

Development of Patient Access to Electronic Health Records as a Step towards Ubiquitous Public eHealth

Jesper Holgersson University of Skövde, Sweden

Gunilla Myreteg Uppsala University, Sweden

Keywords

electronic health record, electronic patient record, eServices, evaluation, patient-centric, public eHealth services, system development process, ubiquitous computing, usability

In this case study, the customer – vendor – end-user relationships in the development of public eHealth services was investigated in practice and led to a number of recommendations to bear in mind when designing ubiquitous public eHealth services.

Isabella Scandurra Uppsala University, Sweden

Thomas Lind Uppsala University, Sweden

European Journal of ePractice · http://www.epractice.eu/en/journal/